Access to Care Analysis
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- Annabella Warner
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1 Access to Care Analysis 1. Introduction As part of the documentation of access to care and service payment rates federal requirements found at 42 CFR , the State must submit an access to care analysis for any service within a state plan amendment that proposes to reduce or restructure provider payment rates in circumstances when the changes could result in diminished access. The access review conducted must demonstrate that access to care is sufficient as of the effective date of the state plan amendment. Further, a state must establish procedures in its Access Monitoring Review Plan (AMRP) to monitor continued access to care after implementation of state plan service rate reduction or payment restructuring. Within 90 days of identifying access deficiencies, the state must submit a corrective action plan with specific steps and timelines to address those issues. While the corrective action plan may include longer-term objectives, remediation of the access deficiency should take place within 12 months. The State must conduct a yearly update to previously submitted access to care analyses on state plan amendments (SPA) that proposes to reduce or restructure provider payment rates for a period of three years as specified in 42 CFR (b)(6)(ii). Oklahoma s (OK) SPA 16-21, psychiatric residential treatment facilities (PRTF) rate reduction revised the payment methodology for private, in-state PRTFs, private psychiatric hospitals (institutions for mental disease), as well as general hospitals with psychiatric units and reduced rates by 15 percent. OK SPA was submitted May 24, 2016, with an effective date of May 1, 2016, and approved on February 17, This is the first annual update to the access to care analysis for the restructured payment methodology within OK SPA From the data gathered for this report, access to care is adequate despite the reduction in rates; please refer to the Effect on Access to Care section below for a more detailed analysis. 2. State Plan Amendment (SPA) OK SPA Psychiatric Residential Treatment Facilities (PRTF) Rate Reduction 3. Analysis of the Effect of the Change in Payment Rates on Access Requested Methodology or Rate Structure The revision to the payment rates for private, in-state PRTFs, private psychiatric hospitals (Institutions for Mental Disease, IMD), and general hospitals with psychiatric units required an amendment to the Title XIX state plan. The rates for the aforementioned settings are 15 percent less than the State Fiscal Year 2015 rates. Rationale of SPA This state plan amendment was necessary to reduce provider reimbursement rates thereby reducing the Oklahoma Department of Mental Health and Substance Abuse Services' (ODMHSAS) operations budget in order to meet the balanced budget Page 1 of 5
2 requirements as mandated by State law. Without the revisions, the Department was at risk of exhausting its State appropriated dollars required to maintain the State's Medicaid Behavioral Health Program. Following an extensive analysis of the potential effect on access to care as noted below, the Department initiated the processes necessary to request this State Plan Amendment. Effect on Access to Care In order to monitor beneficiary utilization of the impacted services, the State relied on the analysis of MMIS data against established baseline data and thresholds. The study included assessments of the available provider network, number of members with a paid claim in the first year of the restructured methodology, and utilization of services over time to determine that access was currently sufficient and access would not be negatively impacted by the rate reduction. Based on the data from Calendar Year (CY) 2016, the number of active Psychiatric Residential Treatment Facilities (PRTF) was 21 centers. Further, based on the same 12-month data and out of 543,126 members, children younger than age 21, eligible for Medicaid as of December 31, 2017, PRTFs served a total of 3,829 members, children younger than age 21 (0.7 percent of the total Medicaid eligible beneficiaries). Compared to CY2015, the data represents no change in the number of contracted PRTFs and a slight decrease of members that accessed independent PRTFs in CY2016. From January 1, 2016 through December 21, 2016, the total number of beneficiaries served decreased by approximately 3 percent or by 124 members. The State surveyed 34 residential/inpatient providers regarding capacity and available bed days. Based on utilization data and survey results, the State paid for 235,676 PRTF patient bed days in CY2016. This is in comparison to the 262,193 bed days in CY2015 (10.11 percent decrease). The remaining available bed capacity within the state's PRTF system was 63,989 patient bed days. This is compared to 114,913 patient bed days in CY2015. After the implementation of the rate reductions, the State has not had a facility turn away a SoonerCare client due to insufficient reimbursement rates. Since 2015, the State has implemented several community based initiatives aimed at reducing inpatient admissions and readmissions such as Health Homes for Children with Serious Emotional Disturbance and Adults with Serious Mental Illness 1, reimbursement for transitional case management and mobile response and stabilization. The State believes that at least a portion of the decreases in the utilization of PRTF services can be attributed to these initiatives. Given this data, the State continues to feel that its PRTF network is sufficient to ensure access to care and services for the SoonerCare population even though less bed days were reimbursed as compared to CY May 2017 Outcomes measures for Health Homes indicate that follow up rates after hospitalization for Mental Illness within 7 days after discharge have gone from 33.8% in June 2016 to 84.2% in March Page 2 of 5
3 Total number of providers and available beds for CY2016: Provider Total Beds PRTFs Bethesda Family Services Foundation 16 Bethesda Family Services 12 Moccasin Bend Ranch 28 Sequel Care of Oklahoma 57 Willow Crest Hospital RTC 43 Parkside Inc 40 Shadow Mountain 54 Shadow Mountain 20 Shadow Mountain Specialty 54 Vista Health Ft. Smith AR 44 Vista Health Fayetteville AR 26 Cedar Ridge 56 Southern Plains Treatment Services 18 Shadow Mountain Hope 17 Shadow Mountain 30 Children's Recovery Center 52 Piney Ridge Center 102 GENERAL HOSPITAL W/ PSYCH UNIT Integris Bass Behavioral Center >16 Integris Bass Behavioral >16 St. Anthony RTC 49 St. Anthony Hospital 36 Willow View Hospital RTC >16 Willow View Hospital RTC >16 Hillcrest Medical Center >16 Positive Outcomes RTC 27 Southwestern Medical Center >16 PRIVATE PSYCHIATRIC HOSPITALS Shadow Mountain Behavioral Health System 60 Cedar Ridge 60 Parkside 30 Vista Health (AR) 34 Vista Health (AR) 38 Willow Crest 10 Rolling Hills 32 Page 3 of 5
4 The Map below demonstrates the geographic areas of PRTFs throughout Oklahoma. 4. Analysis of the Information and Concerns Expressed in Input from Affected Stakeholders General Public Input In order to fulfill the requirements within 42 CFR (b)(6)(ii) regarding continual monitoring of the state plan amendments that propose to reduce or restructure provider payment rates, a draft of the 2017 Access to Care Analysis for the freestanding psychiatric hospitals rate change effective May 1, 2016 was posted on the Agency s Proposed Policy webpage as well as the Native American Consultation webpage for a 30-day public comment and review period from August 3, 2017 through September 2, Page 4 of 5
5 Call Monitoring The OHCA monitors member and provider calls regarding access to care. To date there have been no calls directly pertaining to this budget reduction request. 5. Summary/Conclusion The Agency continues to assert that reducing provider rates as outlined in this analysis allows the State to continue the SoonerCare behavioral health program without drastically reducing the provider reimbursement rates for ALL behavioral health services or eliminating services completely which would have a detrimental impact on access to behavioral health services. Without these rate reductions, the State would be forced to eliminate certain classes of services in order to meet its State constitutional requirement of filing a balanced budget. After careful analysis and stakeholder outreach, the State has determined that reducing provider rates as mentioned above continues to be in the best interest of Oklahoma's Medicaid Behavioral Health Program and the beneficiaries it serves and continues to not have a significant impact on access to care for SoonerCare members. Page 5 of 5
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